Taking stock of dementia
In India, four million people are afflicted with some form of dementia, a number expected to triple by 2050.
A heartening feature of health care in India is how life expectancy has increased — from 32 years in 1947 to 68 years today. However, this has resulted in newer health challenges, notably cancer and dementia. Dementia refers to deterioration in a person’s mental faculties commonly affecting memory, behaviour and thinking and is serious enough to impact the patient’s daily life. Though there are many causes of dementia, the majority of them being untreatable, the commonest one is Alzheimer’s. It affects about 46.8 million people globally, with about 9.9 million new cases annually. In India, four million people are afflicted with some form of dementia, a number expected to triple by 2050.
We know what happens in Alzheimer’s, yet we don’t know why it happens. Alzheimer’s can run in families but whether the trigger is one’s lifestyle, environment, genes or a combination of these is unclear. People with cardiovascular disease have a higher chance of developing Alzheimer’s. No specific test defines Alzheimer’s; it is a diagnosis based on clinical assessment and exclusion of various other causes. There is an insidious and progressive decline in mental functions. These are characterised by memory loss, taking longer to accomplish routine tasks, difficulty in planning/solving problems, poor judgment leading to bad decisions, losing track of time, difficulty in following conversations, mood and personality changes and withdrawal from social activities. Such patients should be evaluated and investigated by a neurologist and the type of dementia characterised. While no cure exists for Alzheimer’s, it is important to catch the ailment in its early stages and initiate certain measures. These include looking at patterned behavioural characteristics, setting routines for mundane tasks and certain medicationsfor managing the behavioural and other symptoms. Efforts are needed to optimise their physical health, maintain hydration and nutrition, and reduce the risk of falls and infection.
The disease has steep personal and societal costs. From an economic viewpoint, the biggest driver of cost is home and hospital care. Indirect cost includes loss or reduction of income of the patient and family members who need to care for them at home. Direct cost increases as the disorder progresses and a formal caregiver is required. These patients are frail and prone to multiple medical morbidities requiring hospitalisation and expensive treatment. With further progression, the patient may need to be permanently institutionalised (in a hospital or old-age facility). The economic burden of Alzheimer’s is an estimated $1 trillion (which representsmore than 1% of global GDP). According to a 2010 report, the economic burden of dementia in India was ₹147 billion, which is expected to rise three-fold by 2030. The annual household cost of care for a person with Alzheimer’s disease is between ₹45,600 and ₹2,02,450 in urban areas and ₹20,300 and ₹66,025 in rural areas. The cost rises with increasing severity of the disease.
In the past, a joint-family setup was the backbone of social security for the aged in India. With changing societal norms, this is being replaced with nuclear families. In addition to this, governmental social security is minimal or non-existent and well-managed old age homes a rarity. Rising cases of dementia and Alzheimer’s patients pose a grave threat to our social development agenda. Primary-care physicians have to be involved in the everyday care of these patients. The role of neurologists is significant in the initial diagnosis, patient treatment, and the training and supervision of primary physicians. A workforce of trained home caregivers is needed to optimally manage these patients. Specialised institutions (more than just old age homes), providing basic care for affected individuals, need to be developed to avoid repeated hospital admissions and overburdening existing health-care institutions.
Health care for patients with dementia has to be continuous, holistic and integrated. Innovative care models which are specific and cost effective for the Indian scenario have to be developed. Copying Western models (of more organised rehab or old age homes and social care institutions) would not be practical as there is no social security or resource available to cater to a population as huge as India’s. Tackling this health issue (this impending yet inevitable epidemic of dementia) will need Herculean efforts which will need to start now. Comprehensive health-care provision for dementia is a social necessity — one that will need political will and sustained efforts by public health policymakers in conjunction with health care and social care professionals.
Dr. V.P. Singh is Chairman, Neurosciences, Medanta – The Medicity